Mgr, Contracting & Payer Relations en SPCP/Southeast Medical Group

Description

The Mgr, Contracting & Payer Relations provides enterprise leadership for the full contract life-cycle with commercial, Medicare Advantage, Medicaid and employer-direct payers. The role designs and executes strategies that maximize revenue, expand value-based/risk programs, assure regulatory compliance, and strengthen relationships for both employed and independent physicians. The Mgr, Contracting & Payer Relations will collaborate with internal stakeholders, including legal, compliance, finance, and operations teams, to optimize contract terms, drive business growth, and mitigate risks. Scope also includes Credentialing and Payer Relations departments. Reporting relationship will be solid-line to Chief Population Health Officer and Payer Strategy.

Requirements

JOB REQUIREMENTS

• Contracting: Develop a Payer Contracting strategy. Review and negotiate Commercial and Medicare Advantage Fee-for-Service and Value-Based agreements as assigned by the supervisor. Prepare contract highlights, profiles, or summaries of key terms as applicable. Communicate contract details to team members and clients as needed. Design, negotiate and manage upside/downside shared savings, capitation, ACO REACH, PCF, MA STARS, and employer bundled-payment models. Define attribution, quality metrics, data-sharing, care-management funding, and performance reconciliation methodologies.
• Contract riteria and Compliance: Ensure all contract criteria, including compliance activities, are identified and addressed. This may involve required policies, delegated credentialing procedures, and various monitoring activities. Maintain a master compliance checklist for each agreement covering Stark, AKS, HIPAA, CMS program integrity, and payer-specific audits. 
• Technology and Tools: Participate in training on payor-specific websites, contract-lifecycle-management systems, or portals to gather or verify payor information. Review payor policies, procedures, and administrative manuals as necessary.
• Resources: Familiarize with resources and information available for agreements. Stay informed about compliance-related requirements, educational opportunities, and relevant resources.
• Project Management: Assist in maintaining the SharePoint contract maintenance log for executed agreements, tracking key terms, and ensuring adherence by contracted entities. Update and submit monthly rosters for joint venture relationships with clients.
• Internal & External Communications: Payor Communications: Lead informational calls and meetings with CMS and commercial payers; disseminate regulatory and contract updates to stakeholders. Association Communications: Prepare agendas, minutes and board packets for CIN/IPA network meetings; implement board decisions. Practice Outreach: Create contract summaries and empirical fee comparisons (“80/20” tables); host webinars and conference calls for practice leaders.
• Monitoring Reports and Implementation: Keep the supervisor and colleagues informed about the contracting status to ensure accurate and timely communication to participating providers, board members, and the management team. Assist with fee solicitations following applicable messenger model or clinically integrated protocols. Engage in compliance monitoring and maintain related logs.
• Credentialing & Delegated Services: Direct NCQA-compliant credentialing/re-credentialing processes; negotiate delegation agreements with defined turnaround guarantees. Produce and submit accurate monthly rosters and directory files to meet payer and No Surprises Act requirements
• Troubleshooting: Anticipate the needs of practices regarding contracting, identify issues that require attention, and proactively address them. Continuously seek ways to improve processes and enhance customer service for participants.

ADDITIONAL RESPONSIBILITIES:

• Maintain confidentiality of corporate, client, and patient information at all times.
• Participate in continuous job-related training and development.
• Perform other work-related duties as assigned.

EDUCATION, EXPERIENCE, and SKILLS REQUIRED:

• Bachelor’s degree preferred. 
• 10+ years progressive payer contracting experience, including 5+ years in value-based/risk models with physician practices/groups..
• Expertise in financial modeling, claims analytics, and Microsoft Excel/PowerPoint; Tableau/Power BI preferred.
• Exceptional negotiation, presentation and writing skills; board-room presence.
• Ability to travel up to 25%.

Key physical and mental requirements:

• Ability to lift up to 50 pounds
• Ability to push or pull heavy objects using up to 50 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving

FLSA Classification: Exempt

Southeast Primary Care Partners is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.